Co-design of a toolkit for Integrated Care Systems to support primary care healthcare professionals to deprescribe unnecessary antidepressants: A behavioural science realist approach

Background 1-in-5 people are prescribed an antidepressant for a common mental disorder (CMD) such as depression and anxiety. The incidence and severity of antidepressant side effects and withdrawal reactions on discontinuation increase with prescribing duration. Continuing to prescribe antidepressants for longer than is necessary therefore causes avoidable patient harm and NHS resource use. There is also significant antidepressant prescribing inequality with people living in the most deprived quintiles being 50% more likely to be prescribed an antidepressant than those living in the most affluent quintile. The Royal College of Psychiatrists recommend prescribing antidepressants for only 6-12 months following symptom resolution and to accompany deprescribing with non-pharmacological support and monitoring for CMD relapse. However, antidepressant deprescribing is not routine practice in primary care; healthcare professionals (HCPs) report barriers including perceiving antidepressant deprescribing as a low priority, a misconception that antidepressants should be prescribed long-term for all patients and fear of the professional consequences if a patient s CMD relapses. The result is that two-thirds of people are prescribed antidepressants without an indication. There is therefore a need for Integrated Care Systems (ICSs) to facilitate primary care HCPs to deprescribe antidepressants safely and effectively. Aim To co-design a Toolkit for ICSs to address the barriers and enablers (determinants) of HCPs safely and effectively deprescribing antidepressants in primary care. The Toolkit will guide ICSs to develop a strategy to facilitate three target HCP behaviours 1) Deprescribe antidepressants, 2) Refer/signpost patients to locally available non-pharmacological support and 3) Monitor for CMD relapse. Methods Phase 1 (M1-7): Drawing on realist principles and behavioural science, we will identify behavioural mechanisms and contexts from academic and grey literature to formulate programme theories (PTs) describing how to facilitate primary care HCPs to undertake the three target behaviours. Phase 2 (M4-10): We will conduct a realist evaluation to test (confirm, refute, refine) the PTs and generate any novel PTs specific to the NHS primary care context. Participants will be recruited from four GP practices purposively sampled to represent salient factors. We will hold separate focus groups/interviews with patients (n=8), HCPs (n=32) and mental health charity/community organisation stakeholders (n=8). Phase 3 (M9-16): We will co-design an ICS Antidepressant Deprescribing Toolkit that addresses the PTs contextualised for the NHS primary care context. Co-design will comprise three rounds of workshops with a sample of Phase 2 participants, plus stakeholders from the wider local ICSs, e.g. leads for mental health and prescribing. We will seek funds to evaluate the Toolkit in a feasibility study and definitive trial across ICSs in a future programme of work. Impact and dissemination Underpinned by an evidence-based framework for dissemination, we will work with our Patient and Public Involvement and Expert By Profession groups to identify our dissemination target audiences. We will design passive and active dissemination activities to share key messages tailored to the audiences and strategies to monitor impact. Passive strategies will include a project website, newsletters and social media presence. Active strategies will include workshops, webinars and discussion fora.